The Journal of the American College of Surgeons (JACS) has an article this month that I missed last fall, originally presented at the Western Surgical Association meeting in California, that explored differences in outcomes of patients with a bowel obstruction who were admitted to either a medical or surgical service.

This takes me back to my Chicago residency days and fond memories of arguing with ER Attendings at 3 AM regarding whether or not the next name on my endless deluge of consults ought to be admitted to surgery or medicine. It got so bad, administration from both the medical and surgical departments had to articulate actual policies on who would admit certain diagnoses. All bowel obstructions went to surgery. Cellulitis to medicine. Cholecystitis to surgery. Cholangitis to medicine with immediate surgery/GI consults. Pancreatitis could go either way. Mild alcohol pancreatitis went to medicine but severe gallstone pancreatitis with a lot of Ranson criteria had to go to surgery. This eliminated a lot of the unhealthy inter-departmental bickering and resentment. But that was a large academic teaching hospital. You could set policies and make residents do what you want. In the world of private practice and community hospitals it's different. I found that many of the cases I had been forced to take on my service as a resident were now being admitted to medicine with surgery consults. I'd get phone calls at 3 AM from laid back, bro-talking ER docs telling me about so and so with a "hot gallbladder" who was being admitted to Dr Johnson and he was hoping I would consult first thing in the morning. Hell yeah, I said. I'm all for that. The reason for the shift soon became clear. Old school medical doctors who take a lot of ER call actually like having a lot of patients on their primary service. Because they have mortgages and car leases and private school tuition to pay. Plus many of them were actually awesome doctors who saw their patients no matter where they needed care and demanded that, if one of their patients was admitted to the hospital, they were notified and had the patient admitted to their own damn service. I liked those guys.

Results: Median LOS among patients whose ASBO resolved nonoperatively was similar for those on SS and MHS (2.85 days vs 2.98 days; p = 0.49). In patients without nonoperative resolution of ASBO, those admitted to MHS had longer median LOS when compared with those admitted to SS (9.57 days vs 6.99 days; p = 0.002) and higher median charges ($38,800 vs $30,100; p = 0.025). Patients admitted to MHS who had an operation, had a greater median TTO than operative patients on SS (51.72 hours vs 8.4 hours; p < 0.001). Multivariate analysis did not identify factors independently predictive of increased LOS, TTO, or charges.Conclusions: Adhesive small bowel obstruction patients are treated in a heterogeneous fashion in our hospital, causing disparate outcomes depending on admitting service when patients undergo operation. Admitting all suspected ASBO patients to SS has the potential to dramatically decrease LOS and reduce waste in those requiring operation, thereby reducing health care expenditures.

NB: MHS = medical hospitalist service, SS = surgery service

The claim is that patients with a primary diagnosis of a small bowel obstruction who end up requiring operative intervention spend more time in the hospital and accrue higher overall hospital costs. Ergo, in order to save costs and get patients home faster, all bowel obstruction cases ought to be admitted to a surgical service.

Several issues here. First, there was no difference in hospital length of stay in patients who resolved their bowel obstructions with conservative management. Which is good, right? But they found that in those patients who required surgical intervention for refractory obstruction, the patients initially admitted to a surgeon's service had an operation quicker and therefore were discharged from the hospital sooner. But are they neglecting selection biases here? In my experience, the patient with a bowel obstruction admitted to a medical service is more likely to be elderly and have multiple co-morbidities (CHF, CAD, DM, COPD, anti-coagulation medicines etc etc). So the ER calls the surgeon at 4 am. Surgeon tells the ER to place NG, start some fluids, and admit to medicine for optimization of medical issues. Surgeon sees patient first thing in the morning and every day thereafter. This is exactly what he would do whether he was the admitting doctor or a consultant. Furthermore, most surgeons are going to treat a more frail/elderly/unhealthy patient a hell of a lot more conservatively before they decide to recommend surgery (assuming the absence of peritonitis/acute abdomen, of course). An 84 year old patient with severe CAD is probably going to get an extra day or two of NG decompression before you whisk her off to the OR. That isn't delayed intervention due to primary service mis-assignment. It's smart clinical judgment. Conversely, the 46 year old lady with no medical problems gets admitted to surgery no questions asked. And if her films are crap in the morning there's a damn good chance she gets added on to OR that afternoon.

Overall, there was no difference in mortality or major morbidity in the two groups. Readmission rates were the same. The paper simply affirms something all us in clinical practice already know. It really doesn't matter whether the patient gets admitted to Dr. Medicine or Dr. Surgery. As long as the surgeon is notified from ground zero and allowed to follow/manage the patient from the very beginning of admission-- either as admitting physician or consultant---then outcomes will be optimized. It's almost unheard of for a patient to be admitted to medicine without a concomitant surgical consult. The paper tries to imply that the patients admitted to the medical service had a delay of surgical intervention because the surgeon was not consulted for an opinion until too much time had elapsed. But they don't document this. It's a major weakness in the paper.

As far as I'm concerned, as long as you let me know a bowel obstruction is in the ER, you can admit him to the psychiatry service for all I care. I'll manage the patient the same way as always.